Biologics such as etanercept, adalimumab, infliximab, and ustekinumab are effective for the treatment of moderateesevere psoriasis.. While this prac-tice is often safe and effective, a sm
Trang 1Dear Editor,
Numerous therapeutic options are available for the treatment of
psoriasis Biologics such as etanercept, adalimumab, infliximab, and
ustekinumab are effective for the treatment of moderateesevere
psoriasis Switching between biologics is common practice that is
used in an effort to achieve these treatment goals While this
prac-tice is often safe and effective, a small subset of patients may
expe-rience significant worsening of psoriasis signs and symptoms after
switching between antitumor necrosis factor (TNF)adrugs.1
We describe a 45-year-old Eurasian man with a long history of
chronic plaque psoriasis and psoriatic arthropathy, who
experi-enced paradoxical worsening of his psoriatic arthritis and
develop-ment of uveitis after switching from infliximab to secukinumab
For his treatment history, methotrexate was tried several times
but the patient experienced severe nausea even at low doses He
received other therapies including phototherapy, acitretin,
cyclo-sporine, etanercept, adalimumab, and ustekinumab but with
sub-optimal control of his joint pains and with secondary failure after
6e9 months of therapy He had greatest success with infliximab
(5 mg/kg), which was able to control his skin and joint pains, but
experienced secondary failure with relapse of his skin lesions
[Pso-riasis Area and Severity Index (PASI) 26.4] after approximately 30
months of therapy Hence, he was switched to secukinumab
300 mg according to the standard regimen After the second
dose, his PASI score improved to 10.8 However, after the fourth
dose in the induction phase, he developed severe uveitis with red
eyes and blurred vision, and aflare of his spondyloarthritis, with
se-vere pain in the neck and spine His skin condition also worsened
with a PASI of 14.5 The patient opted to rotate back to infliximab
for better joint control Inflammatory markers, including C-reactive
protein and erythrocyte sedimentation rate, showed a downward
trend after the patient was switched back to infliximab He was
willing to accept poorer control of his skin condition His eye and
joint symptoms subsequently subsided
Switching biologics may be considered to optimize symptom
control, improve quality of life, and minimize adverse effects
When switching for safety reasons, a washout period is
recom-mended until the safety parameter is normalized or stabilized.2
If switching due to lack of efficacy, a washout period is not
necessary.2
Although the exacerbation of psoriasis in patients treated with TNF antagonists is a known phenomenon, the pathogenesis under-lying this mechanism remains elusive Five types of adverse effects induced by biologic agents have been described (a,b,g,d, and 3) based on immunopathogenesis.3 Psoriasiform eruptions, particu-larly the pustular type, are thought to be due to immune imbalance (g type).3 Increased production of interferon-g after TNF-a
blockage, increased T helper 17 function and a reduction of regula-tory T cells may have a role to play.4
Adalimumab was one of thefirst few TNF antagonists and has been shown to be effective in treating moderateesevere psoriasis with arthritic symptoms In a small retrospective cohort study con-ducted in Taiwan,525% of patients achieved a 75% improvement in their PASI 75 and 75% had an improved Psoriatic Arthritis Response Criteria (PsARC) In recent years, however, newer agents, such as ustekinumab, have been proven to be effective for patients who have failed other biologic agents such as etanercept and/or adali-mumab.6Unfortunately, our patient had suboptimal response to etanercept, adalimumab, and ustekinumab
Secukinumab is a new human interleukin-17 monoclonal anti-body for treating moderateesevere psoriasis To date, there have been no reports of worsening of psoriasis or its associated symp-toms after switching to secukinumab However, paradoxical exacer-bation of Crohn’s disease in a clinical trial of secukinumab has been described.7Depending on the local cytokine environment, T helper
17 cells may be primed to be either proinflammatory or regulatory.7 This may explain the paradoxical reactions seen
The immunopathogenesis through which adverse and paradox-ical reactions may occur with biologic agents is indeed complex Therefore, predicting these reactions might prove a major chal-lenge This case highlights the possibility that anti-interleukin-17 drugs, like anti-TNF agents, may also be associated with paradoxical worsening of symptoms in psoriasis patients While this trend is rare, physicians should exercise vigilance and closer monitoring when switching patients between biologic therapies
Peiqi Su*, Jiun Yit Pan National Skin Centre, 1 Mandalay Road, Singapore, Singapore
* Corresponding author National Skin Centre, 1 Mandalay Road, Singapore 308205,
Singapore E-mail address: peiqi_su@nuhs.edu.sg (P Su).
References
Conflicts of interest: The authors declare that they have no financial or
non-financial conflicts of interest related to the subject matter or materials
discussed in this article.
Contents lists available atScienceDirect
Dermatologica Sinica
j o u r n a l h o m e p a g e : h t t p : / / w w w d e r m - s i n i c a c o m
DERMATOLOGICA SINICA xxx (2016) 1e2
http://dx.doi.org/10.1016/j.dsi.2016.10.002
1027-8117/Copyright © 2016, Taiwanese Dermatological Association Published by Elsevier Taiwan LLC This is an open access article under the CC BY-NC-ND license ( http://
Please cite this article in press as: Su P, Pan JYParadoxicalflare of psoriasis, psoriatic spondyloarthritis, and psoriatic uveitis after switching from
infliximab to secukinumab, Dermatologica Sinica (2016), http://dx.doi.org/10.1016/j.dsi.2016.10.002
Trang 22 Kerdel F, Zaiac M An evolution in switching therapy for psoriasis patients who
of tumor necrosis factor in collagen-induced arthritis reveals a novel
treating moderate to severe psoriasis patients with psoriatic arthritis in Taiwan.
pa-tients with moderate-to-severe psoriasis who had inadequate therapeutic
response to previous tumor necrosis factor blockers Dermatol Sinica 2015;33:
Received: May 26, 2016 Revised: Sep 19, 2016 Accepted: Oct 19, 2016
Correspondence / Dermatologica Sinica xxx (2016) 1e2 2
Please cite this article in press as: Su P, Pan JYParadoxicalflare of psoriasis, psoriatic spondyloarthritis, and psoriatic uveitis after switching from
infliximab to secukinumab, Dermatologica Sinica (2016), http://dx.doi.org/10.1016/j.dsi.2016.10.002